1. Field of the Invention
The present invention relates to the field of medical devices, particularly to catheter medical devices, and to catheters for the delivery of cells to tissue in patients. More particularly, the present invention relates to catheters or delivery system designs to improve cell survivability during transportation and/or delivery.
2. Background of the Art
Oxygen is a crucial nutrient for human cells. Cell damage may result from oxygen deprivation for even brief periods of time, which may lead to organ dysfunction or failure. For example, heart attack and stroke victims experience blood flow obstructions or diversions that prevent oxygen from being delivered to the cells of vital tissues. Without oxygen, the heart and brain progressively deteriorate. In severe cases death results from complete organ failure. Less severe cases typically involve costly hospitalization, specialized treatments and lengthy rehabilitation.
Blood oxygen levels may be described in terms of the partial pressure of the oxygen dissolved in the blood (O2). Typically, for arterial blood, normal blood oxygen levels (i.e., normoxia or normoxemia) range from 90-110 mm Hg. Hypoxemic blood (i.e., hypoxemia) is arterial blood with an O2 less than 90 mm Hg. Hyperoxic blood (i.e., hyperoxemia or hyperoxia) is arterial blood with an O2 greater than 400 mm Hg (see Cason et. al (1992), Effects of High Arterial Oxygen Tension on Function, Blood Flow Distribution, and Metabolism in Ischemic Myocardium, Circulation, Vol. 85, No. 2, pp. 828-838), but less than 760 mm Hg (see Shandling et al. (1997), Hyperbaric Oxygen and Thrombolysis in Myocardial Infarction: The xe2x80x9cHOT MIxe2x80x9d Pilot Study, American Heart Journal, Vol. 134, No. 3, pp. 544-550). Hyperbaric blood is arterial blood with an O2 greater than 760 mm Hg. Venous blood typically has an O2 level less than 90 mm Hg. In the average adult, for example, normal venous blood oxygen levels range generally from 40 mm Hg to 70 mm Hg.
In patients who suffer from acute myocardial infarction, if the myocardium is deprived of adequate levels of oxygenated blood for a prolonged period of time, irreversible damage to the heart can result. Where the infarction is manifested in a heart attack, the coronary arteries fail to provide adequate blood flow to the heart muscle. Treatment of acute myocardial infarction or myocardial ischemia often comprises performing angioplasty or stenting of the vessels to compress, ablate or otherwise treat the occlusion(s) within the vessel walls. For example, a successful angioplasty increases the size of the vessel opening to allow increased blood flow.
To reduce the risk of tissue injury typically associated with treatments of acute myocardial infarction and myocardial ischemia, it is usually desirable to deliver oxygenated blood or oxygen-enriched fluids to at-risk tissues. Tissue injury is minimized or prevented by the diffusion of the dissolved oxygen from the blood or fluids to the tissue and/or blood perfusion that removes metabolites and that provides other chemical nutrients.
Conventional methods for the delivery of oxygenated blood or oxygen-enriched fluids to at-risk tissues involve the use of blood oxygenators. Such procedures generally involve withdrawing blood from a patient, circulating it through an oxygenator to increase blood oxygen concentration, and then delivering the blood back to the patient. One example of a commercially available blood oxygenator is the Maxima blood oxygenator manufactured by Medtronic, Inc., Minneapolis, Minn.
There are drawbacks, however, to the use of a conventional oxygenator in an extracorporeal circuit for oxygenating blood. Such systems typically are costly, complex and difficult to operate. Often a qualified perfusionist is required to prepare and monitor the system.
Conventional oxygenator systems also typically have a large priming volume, i.e., the total volume of blood contained within the oxygenator, tubing and other system components, and associated devices. It is not uncommon in a typical adult patient case for the oxygenation system to hold more than one to two liters of blood. Such large priming volumes are undesirable for many reasons. For example, in some cases a blood transfusion may be necessary to compensate for the blood temporarily lost to the oxygenation system because of its large priming volume. Heaters often must be used to maintain the temperature of the blood at an acceptable level as it travels through the extracorporeal circuit. Further, conventional oxygenator systems are relatively difficult to turn on and off. For instance, if the oxygenator is turned off, large stagnant pools of blood in the oxygenator might coagulate.
Perhaps one of the greatest disadvantages to using conventional blood oxygenation systems is that the maximum partial pressure of oxygen (O2) that can be imparted to blood with commercially available oxygenators is about 500 mm Hg. Thus, blood O2 levels near or above 760 mm Hg cannot be achieved with conventional oxygenators.
U.S. Pat. No. 6,180,059 describes a system for the preparation and delivery of a gas-enriched fluid. In applications involving the prevention of ischemia or the treatment of ischemic tissues, the system may be used for the preparation and delivery of an oxygen-enriched fluid including blood to a specific location within a patient""s body. The system may include a circuit for oxygenating or enriching blood, e.g., increasing the level of dissolved oxygen in the blood. The system includes an apparatus that combines a gas-supersaturated fluid with blood to form a gas-enriched fluid, advantageously for regional or localized delivery. The gas-supersaturated fluid may include an oxygen-supersaturated physiologic liquid, and the blood to be enriched is blood withdrawn from the patient. The system provided further includes assemblies for supplying controlled flows or supplies of the gas-supersaturated fluid and the blood. The system includes an elongated, generally tubular assembly including a central lumen and at least one end placeable within a patient body proximate a tissue site to be treated, the end including an outlet port for the gas-enriched fluid. The system may include a catheter defining a fluid pathway, including a proximal portion adapted for coupling to supplies of gas-supersaturated fluid and blood, and a distal portion defining a fluid pathway removably insertable within a patient""s body, for infusing the gas-enriched fluid to predetermined sites.
U.S. Pat. No. 6,030,358 describes an apparatus for performing site specific microtherapy comprising a pump reservoir and one or more microcatheters dimensioned to be positioned within a tissue site for selectively removing fluids by microdialysis from the tissue""site, the microcatheter(s) being adapted for fluid communication with the pump reservoir to effect the recovery of fluid, the apparatus further comprising a delivery sheath adapted to be positioned into the tissue site, the microcatheter assembly adapted to be positioned within the delivery sheath, the delivery sheath having walls sufficiently permeable to permit a desired flow of fluids between the tissue and the microcatheter assembly in the course of microdialysis. A kit may comprise the apparatus wherein the microcatheter assembly comprises a plurality of microcatheters adapted to be positioned within the delivery sheath. The microcatheter assembly may be adapted to perform microdialysis based on size exclusion in order to remove tissue fluids and solutes based on solute size. The microcatheter assembly may also comprise a plurality of microcatheters, each in the form of a capillary tube having a lumen and semipermeable wall and the apparatus provides a plurality of fluid passageways.
Medical technology has advanced dramatically and swiftly over the past decades. The advances have been particularly significant within the fields of genetic engineering, cell technology, and in their proposed uses in actual therapies. For example, it is an increasingly common proposed medical technique to inject live cells into the human body. The intention of these cell implantation therapies (with genetically engineered cells or harvested cells) is to have the implanted cells attach to or settle into the tissues and provide their essential functions in their new location. The function of these therapeutic techniques may be to repair a genetic defect (producing a needed substance that the body is failing to create), repair traumatic damage, replace disease-diminished cells, contribute to the mechanical properties of an organ by the structures they build, and so forth. The science of cell implantation therapy is far in advance of the engineering technology needed to implement these therapies.
One engineering problem that is considered here is an appreciation of the fact that not all cells survive the injection process. When a substantial fraction of the cells fails to settle and function in the body, the efficacy of the treatment is much reduced. Although some cell deterioration is expected, there has been almost no consideration in the literature of this problem. There has been little publication on the design and engineering of delivery systems to reduce the impact of the delivery system on aggravating normal loss of viable cells.
U.S. Pat. No. 5,997,525 describes a system for delivering therapeutic or diagnostic agents to the heart, including a catheter that delivers the material to be delivered in a viscous carrier. The material may be delivered in association with an elongated, flexible transmission means for lasing that forms channels in the heart wall, as delivery locations.
U.S. Pat. No. 5,993,462 describes a shapeable catheter, which may include a pre-shaped region bent into a predetermined shape. A lumen may be proportioned to slidably receive a core wire. A pull wire may be provided to allow the user to cause deflection at a distal portion of the catheter.
U.S. Pat. No. 5,980,885 describes a method for inducing in vivo proliferation of precursor cells located in mammalian neural tissue. Simple glass pipettes are used to deliver the cell suspensions at levels of about 50,000 cell/microliter.
As can be seen from this review of the prior art, the delivery systems described tend to be essentially primitive tubes, with no consideration of flow functions or physical effects on cells during the delivery process. To assure that cell implantation becomes a viable procedure, it is essential that engineering considerations be used in the design of the pick-up, transportation and cell delivery devices.
Recent research suggests that improvements in cell delivery techniques may enhance the therapeutic efficacy of cell therapy. Multiple factors appear to influence long-term cell implant viability, including the site of the cell implant placement, the type of cells used in the implant, and the techniques used in the preparation of the cells to be transplanted. However, even when all of the above factors are taken into account, only 3-20% of implanted cells survive more than seven days. Membrane trauma and other related factors associated with the implantation process and cell delivery device appear to play a role in the high cell attrition rate. Improvements to the implantation methodology may be highly beneficial to increase cell survivability. Research data also indicate that the high attrition rate of transplanted cells may result from a lack of nutritive support due to inadequate local blood flow. Thus, there may be merit in using image-guided catheter devices to prepare and treat the tissue transplant area pre- and post operatively.
Recent research also indicates that optimal treatment of Parkinson disease (PD) patients may require that multiple locations within the brain be targeted for cell implants. At present, cell delivery over anatomically extensive regions of the brain involves multiple stereotactic probe placements, with concomitant invasion and damage to the overlying layers of healthy tissue. Additional catheter insertions may subsequently be required if nerve growth factors or other nutritive agents are to be infused. The development of a cell delivery device that reduces the number of insertion trajectories required for cell delivery could therefore significantly lower neurosurgical operating time and reduce surgical risk.
Targeted cell and drug delivery into the brain requires precise anatomic localization of normal and abnormal tissues. Present systems of image-guided placement of intracranial probes, such as drug delivery catheters, include framed and frameless technologies, which typically use images acquired preoperatively to create a three-dimensional space on which the surgical navigation is based. Framed systems use externally applied frames to establish the fiducials for navigation, whereas frameless systems use optical, electromagnetic, or ultrasound sensors and mechanical arms to track the position of surgical tools and instruments during surgical procedures.
The use of MRI to provide intraoperative imaging guidance is a relatively new concept made feasible by the development of new MRI systems that provide high spatial and temporal resolution imaging in conjunction with multiplanar and volumetric three-dimensional data acquisition, thereby making possible interactive image plane definition to facilitate surgical localization and targeting of a lesion and improving intraoperative navigation. Intraoperative MR imaging enables the surgeon to noninvasively visualize tissue planes beyond the surface of the tissue under direct evaluation during a clinical procedure. Moreover, MR imaging enables differentiation of normal from abnormal tissues, and it can display critical structures such as blood vessels in three dimensions. Thus, high-speed MR-guided therapy offers an improved opportunity to maximize the benefits of minimally invasive procedures in real-time.
MR imagers which permit continuous real-time visualization of tissues during surgical and endovascular procedures have already been developed. U.S. Pat. Nos. 5,410,287, 5,519,372, 5,565,831 and 5,713,357 provide illustrative examples of such systems. Newer generations of MR scanners provide frequently updated images of the anatomical structures of interest. This close to real-time imaging capability makes it possible to use high-speed MR imaging to observe the effects of specific interventional procedures, such as endovascular catheter tracking and intracranial administration of drug agents to targeted tissues, as disclosed by U.S. patent applications Ser. No. 08/857,043, Ser. No. 08/856,894, Ser. No. 08/916,596, Ser. No. 09/131,031, and Ser. No. 09/174,189.
Cell and drug delivery devices, such as catheters that are MR-visible, can be monitored by MR imaging, thus making intraoperative verification of catheter location possible during MR-guided procedures. U.S. patent application Ser. No. 08/857,043 describes a method for MR image-guided drug delivery. U.S. patent applications Ser. No. 08/856,894 and Ser. No. 08/916,596 disclose active MR visualization of catheters and other interventional probes by means of radiofrequency microcoils positioned at specific locations along the distal axis of the device. U.S. patent application Ser. No. 09/131,031 discloses a method and medical device for neurological interventions using nonlinear magnetic stereotaxis combined with MR imaging in order to perform image-guided targeted drug delivery in the brain. Alternative means of using MR signals to localize and track devices with small coils that are placed within the body are taught by U.S. Pat. Nos. 5,211,165, 5,307,808, 5,318,025 and 5,715,822.
Implantable miniature osmotic pumps, such as disclosed, by U.S. Pat. No. 4,475,916 to Himmelstein, et al. have been used to provide a continuous supply of drugs or other active biologic factors to the brain and other tissues at a controlled rate. Reservoir limitations as well as drug solubility and stability have, however, restricted the usefulness of this technology. Controlled sustained release of dopamine has been attempted from within bioabsorbable microcapsules, such as disclosed by U.S. Pat. Nos. 4,391,909 to Lim, U.S. Pat. Nos. 4,673,566, 4,689,293 and 4,806,355 to Goosen, et al., U.S. Pat. No. 4,803,168 to Jarvis and U.S. Pat. No. 4,883,666 to Sabel, et al. However, this method, appears to rely on surface erosion of the bioabsorbable polymer, which is in turn influenced by various hydrolytic events, thereby increasing the likelihood of drug degradation, and rendering predictable release rates difficult. A further problem appears to be attributable to limited diffusional surface area per unit volume of larger size microspheres, such that only a limited volume of cells can be loaded into a single microcapsule.
Exemplary of implantable microporous devices for drug delivery are U.S. Pat. No. 3,993,072 to Zaffaroni, U.S. Pat. No. 4,298,002 to Ronel, et al., and U.S. Pat. No. 4,309,996 to Theeuwes. U.S. Pat. No. 5,104,403 to Brotsu, et al., discloses a vascular prosthesis with a low porosity outer material and a inner synthetic tubular mesh, in which semi-permeable microcapsules that contain hormone producing cells are placed between the outer material and the inner mesh, wherein blood flow through the vascular prosthesis allows for metabolism of the cells and circulation of the hormones. U.S. Pat. No. 5,171,217 to March, et al discloses a method for delivering drugs to smooth muscle cells lining blood vessels utilizing balloon catheter procedures and direct pressure delivery. However, unlike the present invention, the device patented by Brotsu, et al. does not disclose a method of MRI-guided intraparenchymal delivery and monitoring of cell therapy. U.S. Pat. No. 5,800,392 to Racchini describes a microporous balloon catheter for drug delivery where the catheter lumen is in fluid communication with the microporous balloon. This device is designed to deliver drugs and not contain or maintain cells. Fluid enters or exits the balloon via the catheter lumen and is not designed to have external flow circuits through the balloon. Furthermore, the catheter lumen wall is not formed by a microporous membrane.
Macroencapsulation, which generally involves loading cells into hollow fibers and then sealing the ends of the fibers, has also been used to deliver therapeutic drugs into the central nervous system. Exemplary of the macroencapsulation approach to drug delivery is U.S. Pat. No. 4,892,538 to Aebischer, et al., which discloses methods for delivery of a neurotransmitter to a target tissue from an implanted, neurotransmitter-secreting cell culture within a semi-permeable membrane, wherein the surgically implanted cell culture device may be retrieved from the brain, replaced or recharged with new cell cultures, and re-implanted. U.S. Pat. No. 5,106,627 to Aebischer et al. additionally discloses a method for the combined delivery of neurotransmitters and growth factors from implanted cells encapsulated within a semi-permeable membrane. However, while these methods may offer the advantage of easy retrievability, the encapsulation of cells within macrocapsules implanted in the brain is often complicated by unreliable closure of the reservoir resulting in inconsistent results.
Studies utilizing implantation of cells capable of producing and secreting neuroactive factors directly into brain tissue have demonstrated that Parkinson""s disease symptoms can be improved by transplanting fetal dopamine cells into the putamen of the brain of patients with Parkinson""s disease. U.S. Pat. No. 5,487,739 to Aebischer, et al. discloses a cell therapy delivery method utilizing a cannula, obdurator, and implantable cells, wherein the biologically active factors diffuse into brain tissue through an implanted semi-permeable membrane. U.S. Pat. No. 5,006,122 to Wyatt, et al. discloses an apparatus for transplanting tissue into a brain, comprising a stereotactic device for inserting a guide cannula to a target location within the brain into which a second cannula containing the tissue transplant is inserted and the tissue is deposited.
However, a major problem for this emerging therapy is the limited and variable supply of human fetal tissue and the societal issues associated with its use. Fetal pig neural cells have also been shown to survive in an immuno-suppressed parkinsonian patient. Improvements in the quality of transplantation also appear to be emerging. Recent studies, for example, Zawada, et al,. Naturexe2x80x94Medicine, Vol. 4, pps. 568-574 (1998) have demonstrated that somatic cell cloning can efficiently produce transgenic animal tissue for treating parkinsonism. It is also possible to surgically remove neural progenitor cells from a patient, grow the cells in culture, insert therapeutic genes, and then replace the transfected cells back into the patient""s brain. However, the ability to monitor correct cell placement non-invasively with MR imaging is not currently available. Moreover, unlike the present invention, the previous studies and patented cell delivery methods may not permit non-invasive monitoring of the viability of the cells following their implantation into tissue.
Thus, there exists a need for an improved image-guided method to deliver cells that can produce biologically active factors to a target region of the brain. In addition, there is a need for a method to monitor non-invasively the ongoing viability of the cell implant, in particular to determine whether the cells are adequately perfused by the local microvasculature and continue to provide sustained and controlled delivery of the deficient biologically active factor.
Current methods of catheterization of the parenchymal tissues of the brain make it possible to measure intracranial pressure (U.S. Pat. No. 5,107,847), deliver drugs in a rate-controlled manner (U.S. Pat. No. 5,836,935), infuse various substances into the brain (U.S. Pat. No. 5,720,720), and convey fluids out of the brain (U.S. Pat. No. 5,772,625). U.S. Pat. Nos. 5,843,150 to Dreessen, et al, 5,861,019 to Sun, et al, 5,843,148 to Gijsbers, et al, 5,820,589 to Torgerson, et al, 5,821,011 to Taylor, et al., 5,826,576 to West, 5,858,009 to Jonkman, and PCT application W09807367A1 to Jolecz, et al provide additional illustrative examples of such multi-probe systems.
Very recent technological developments are now leading to intraparenchymal catheterization systems that can be positioned within the brain by magnetic stereotaxis (U.S. Pat. Nos. 5,125,888; 5,707,335; 5,779,694), that are visible under magnetic resonance (MR) imaging (U.S. patent application Ser. No. 09/131,031), and that contain multi-purpose electrodes (U.S. Pat. No. 5,843,093). In addition, there are several types of implantable neurostimulator devices that have been disclosed. These include those described by Otten (U.S. Pat. No. 5,344,439), Hess, et al. (U.S. Pat. No., 4,800,898), and Tarjan, et al. (U.S. Pat. No. 4,549,556) as three examples thereof.
U.S. Pat. No. 5,108,364 to Takezawa et al. discloses a monitoring catheter for medical use compressed of multiple tubes equipped for fluid delivery and removal, pressure measurement, and temperature measurement.
U.S. Pat. No. 5,113,868 to Wise et al. discloses a pressure sensing catheter system comprising a catheter, a pressure sensor, and a signal conduit Dumoulin et al., U.S. Pat. No. 5,255,680 to Darrow and Dumoulin, U.S. Pat. No. 5,307,808 to Dumoulin et al., and U.S. Pat. No. 5,318,025 to Dumoulin et al. additionally disclose a tracing system in which radiofrequency signals emitted by an invasive device, such as a catheter, are detected and used to measure the device""s position and orientation in a patient. Localization of devices in situ is achieved by transmit radiofrequency coils positioned at its distal end, which are detected by receive radiofrequeney coils positioned around the imaging volume of interest. The position of the device, as determined by the tracking system, is superimposed upon independently acquired diagnostic images. U.S. Pat. No. 5,383,454 to Bucholz discloses a system for indicating a position of a tip of a probe which is positioned within an object on images of the object, wherein a computer employing transactional software translate the position of the tip of said probe into a coordinate system corresponding to the coordinate system of the cross-sectional images.
Each of the above-cited patents provide advantages and disadvantages for monitoring of physiologic parameters related to cell and drug therapy. However, none of the available methods of intraparenchymal catheterization can carry out multiple input-output functions at the same time with the same implanted device. Moreover, none of the above cited patents disclose a device and method means for targeted delivery of cells, with and without supportive intracranial drug therapy, as well as the monitoring of cell viability, as does the present invention. Also, none of the above cited patents disclose a method means for use of a device for acute and chronic delivery of cells into the human central nervous system during magnetic resonance (MR) imaging procedures, in particular during the injection or infusion of therapeutic stem cells into the brain parenchyma.
PCT WO97/40871 to Elsberry, et al. discloses an implantable pump and catheter for infusing drugs into the brain to treat movement disorders, wherein a sensor detects the symptoms resulting from the movement disorder and a microprocessor algorithm analyzes the output from the sensor in order to regulate the amount of drug delivered to the brain. U.S. Pat. No. 5,607,418 to Arzbaecher discloses an implantable drug delivery apparatus comprising a housing with a plurality of drug compartments which can be opened in a timed manner by a gas generating element to release the drugs into the tissue.
The present invention discloses a device and method means for intraparenchymal cell therapy, particularly during MR image-guided neurosurgical procedures, wherein the cells are provided with sufficient gases and a cell-safe transporting system to assist in maintaining cell viability during the therapy.
The operational characteristics of the present invention offer several conceptual and practical advantages over existing cell and drug delivery devices, which may be summarized as follows:
(a) The device disclosed by the present invention is designed to deliver cells into the brain with little or no damage to the cells. The cells are minimally affected by frictional drag forces along the catheter wall, by surface abrasion trapping on the inside surface of the catheter, and by thermal, mechanical and other forms of dynamic or hydrodynamic shock that might cause rupture of the cell membrane.
(b) The delivery device disclosed by the present invention has a geometry optimized to facilitate cell transport from a reservoir holding the cells through the interconnecting tubing into the catheter tip. In particular, the present device prevents xe2x80x9cpuddlingxe2x80x9d or any other form of aggregation of the cells throughout the flow conduit of the device.
(c) Cells may be per-loaded and cryopreserved in this device. Delivery of cells would entail warming the device and removing cryoprotectants by dialysis, in-situ, prior to injecting cells into target tissue.
(d) The device disclosed by the present invention causes little or no damage to the brain during insertion and removal. In particular, the outer coating of the catheter is lubricious and thereby minimizes xe2x80x98dragxe2x80x99 on brain tissues during insertion and removal.
(e) The design of the present device results in little or no reflux of the injection containing the cells during cell delivery and after withdrawal of the device from the brain.
(f) The tip of the present catheter device is visible on MRI to facilitate accurate placement of the device into target brain tissues. At the same time, MR imaging of the device in situ is free of imaging artifacts which could obscure accurate positioning of the catheter tip.